Plate 01
Asteatotic Eczema
Also called: Eczema craquelé · Xerotic eczema · Winter eczema
Eczema & dermatitisClinical photographs
5 photographs · shown uncropped
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Asteatotic Eczema : Xerosis with mild erythema and fine superficial fissures forming a characteristic reticulated, “cracked” appearance. Source : © DermNet New Zealand. Asteatotic eczema. https://dermnetnz.org/topics/asteatotic-eczema -
Asteatotic Eczema : Marked xerosis with erythematous, scaly plaques and a network of superficial fissures. Source : © DermNet New Zealand. Asteatotic eczema. https://dermnetnz.org/topics/asteatotic-eczema -
Asteatotic Eczema : Poorly demarcated erythematous plaques with fine scaling, symmetrically distributed over the tibias. Source : © DermNet New Zealand. Asteatotic eczema. https://dermnetnz.org/topics/asteatotic-eczema -
Asteatotic Eczema : Severe xerosis with marked erythema, scaling, and prominent superficial fissures forming a characteristic polygonal network. Source : © DermNet New Zealand. Asteatotic eczema. https://dermnetnz.org/topics/asteatotic-eczema -
Asteatotic Eczema : Diffuse erythema with lamellar scaling and multiple superficial fissures producing the characteristic “cracked porcelain” appearance. Source : © DermNet New Zealand. Asteatotic eczema. https://dermnetnz.org/topics/asteatotic-eczema
Clinical images provided for educational purposes.
General information
- Inflammatory dermatitis developing on very dry skin due to impaired epidermal barrier function and excessive water loss
- Characterized by a distinctive “cracked porcelain” or “dried riverbed” appearance created by a network of superficial fissures
- Most common in older adults
- Often worsens during winter when there is less environmental humidity and indoor heating further dries the skin
- Predisposing factors: frequent or hot baths, harsh soaps and detergents, dry surroundings, and direct heat
- Some medications, including diuretics (“water pills”) and oral retinoids, can cause dry skin
- Less commonly, severe or newly acquired disease may be linked to hypothyroidism, poor nutrition, major weight loss, acquired ichthyosis (a condition that causes scaly skin), or systemic disease
Symptoms / presentation
- Very dry, rough, scaly skin
- Variable pruritus, which may be significant
- Tightness or burning may occur
- Characteristic worsening during cold, dry weather (autumn and winter)
- Fissures may become painful if severe
- Frequently recurring during winter if underlying xerosis is not controlled
Clinical exam
- Marked xerosis +++
- Fine superficial erythematous fissures forming a polygonal network
- Classic “cracked porcelain” or “crazy paving” appearance
- Fine white scaling
- Excoriations may occur secondary to scratching
- In severe cases where inflammation is more important, can cause edema, small vesicles, or fluid leaking from the skin
Distribution
- Anterior lower legs/shins+++ : classic location
- Often begins on one shin before involving both
- Thighs
- Arms and forearms
- Trunk sometimes
- May become more widespread in severe disease
Dermoscopy
- White scales following the fissure network
- Sometimes there can be a double free edge of scale arranged linearly, producing a rail-like appearance
- Variable pink-red background
- Irregular dotted vessels and yellow-orange serocrusts may occur in more inflammatory lesions
Diagnosis
- Primarily a clinical diagnosis based on the characteristic cracked appearance
- Laboratory testing is generally unnecessary
- Consider thyroid testing when clinical features suggest hypothyroidism
- Biopsy is rarely required and is generally reserved for atypical or resistant disease
Differential diagnosis
- Nummular eczema
- Irritant or allergic contact dermatitis
- Psoriasis
- Dermatophytosis
- Stasis dermatitis
- Acquired ichthyosis
- Cutaneous T-cell lymphoma in atypical persistent presentations (rarely)
Treatment plan
- Main goal: repair the skin barrier and reduce dryness
- Apply a thick, rich moisturizer several times a day, especially right after bathing while the skin is still slightly damp
- Petroleum jelly or rich creams and ointments are good options
- Prefer ointments and creams over watery lotions
- Take short, lukewarm showers instead of long, hot showers and minimize soap use
- Avoid bubble baths, harsh cleansers, and direct heat exposure
- Consider using a humidifier if indoor air is very dry
- For inflammation, use a mild to medium-strength topical corticosteroid, preferably ointment, for a short time. Ex: triamcinolone 0.1% once or twice daily for approximately 1-2 weeks
- Continue regular moisturizing after resolution to reduce recurrence
- Systemic antibiotics only indicated for secondary bacterial infection
- Treat associated conditions, such as venous hypertension, hypothyroidism, and malnutrition
References
- DermNet. Asteatotic eczema (eczema craquelé).
- Srivastava D, Sathe NC, Persaud Y. Asteatotic Eczema. StatPearls Publishing; updated 2026.
- Chan CX, Zug KA. Diagnosis and Management of Dermatitis, Including Atopic, Contact, and Hand Eczemas. Med Clin North Am. 2021;105(4):611-626.
- Bolognia JL, Schaffer JV, Duncan KO, Ko CJ. Dermatology Essentials. Elsevier.
- Cleveland Clinic. Asteatotic (Xerotic) Eczema: Symptoms, Causes & Treatment.
- Wolff K, Johnson RA, Suurmond D. Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology. McGraw-Hill.